5urdi(al  £m% 


■i       Service  of 

R  R  BIGGAR,  Jr.,  M.  D. 


> 


it 


fevii 


A  -■ 


%- 


AC'ft 


j.    /i   ' 


,J-: 


'.■■-.'y\   ::^--^.  "  .a.'N..>.""  '■  '-!.-■■  ': 


■  /'-^■.i    y 


SURGICAL  CASES 

SERVICE  OF 

H.RBIGGAR,Jr.,M.D. 


The  Surgical  Institute,  ) 
Ci^EVELAND,  May,  1896.    ) 

Case  I. — Mrs.  S. — aet.  50.  Two  years  ago  was 
operated  on  by  a  skilled  surgeon  for  carcinoma  of  the 
mamma ;  it  returned,  and  she  consulted  me  for  a  second 
operation.  The  disease  was  located  in  the  old  cicatrix 
and  had  encroached  upon  the  axilla.  The  incision  fol- 
lowed the  scar  of  the  former  operation  and  the  cicatri- 
tial  tissue  was  dissected  away.  1  he  axillary  glands  were 
found  to  be  enlarged  and  hard ;  they  were  carefully  re- 
moved one  by  one  far  up  in  the  arm  pit  and  a  short  dis- 
tance down  the  arm.  The  indurations  followed  closely 
the  course  of  the  large  vessels,  and  in  particular  the 
axillary  vein.  Some  of  the  glands  were  attached  to  the 
sheath  of  the  vein  itself  and  required  most  careful  dis- 
section to  remove  them  without  injury  to  the  vessel. 
They  extended  up  into  the  space  of  Mohrenheim  and 
even  so  far  as  the  internal  surface  of  the  clavicle. 

The  dissections  in  the  proximity  of  the  large  blood 
vessels  were  entirely  done  with  the  fingers.    After  all 


the  enlarged  glands  had  been  removed  and  the  oozing 
of  the  small  vessels  stopped  by  means  of  pressure  with 
iodoform  gauze,  the  incision  was  closed  with  a  contin- 
uous catgut  suture.  Three  silkworm  gut  sutures  were 
put  in  as  stays.  A  strip  of  iodoform  gauze  was  left  in 
the  axillary  extremity  of  the  wound  for  drainage ;  also 
at  the  lowest  point  of  the  subcutaneous  wound  a  punc- 
ture was  made  with  a  knife  through  the  skin  and  a' 
glass  drainage  tube  introduced.  The  wound  was 
dusted  with  iodoform  and  dressed  antiseptically  with 
iodoform  and  sublimated  gauzes,  cotton  and  a  many- 
tailed  bandage  over  all.  In  twenty-four  hours  the 
dressings  were  saturated  with  watery  exudate.  They 
were  changed,  and  in  forty-eight  hours,  the  dress- 
ings being  clean,  both  drainages  were  removed  and 
the  loose  stitch  drawn  taut 

Against  all  persuasion,  the  patient  refused  to  remain 
in  the  hospital  longer  than  six  days,  as  she  felt  so 
well,  and  returned  home.  Her  family  physician  re- 
ports a  rapid  recovery  to  health  v/ith  no  return  so  far, 
though  only  eighteen  months  have  elapsed. 

Of  all  tumors  of  the  breast,  carcinoma  occurs  in 
about  87  per  cent.  Operative  procedure  must  be 
done  early  in  the  course  of  the  disease,  in  fact, 
an  early  diagnosis  is  most  important  to  cure.  Hal- 
stead  finds  that  by  his  operation  lie  lowers  the  mortal- 
ity considerably.  By  the  old  method  of  the  simple 
elliptical  incision,  the  short  axis  of  the  ellipse  hardly 
brought  the  incision  free  from  the  skin  involvement. 
Then  the  circular  incision  was  used  and  is  still  today. 
But  as  the  sheath  of  the  pectoralis  muscle  is  frequently 
involved,  and  even  the  muscle  itself,  Halstead  began 
his  incision  high  up,  almost  over  the  outer  end  of  the 
clavicle,  and  by  sweeping  inwards  and  downwards, 


toward  the  sternum,  encircled  the  breast,  ending  in  the 
first  line  of  incision.  He  removes  the  breast,  pector- 
alis  major  and  all  the  glands  in  this  region,  in  Mohren-, 
heim's  space  and  in  the  axillary  space.  He  finds  that 
a  higher  percentage  of  those  operated  on  pass  the  3^ 
year  limit,  and  surely  in  this  dread  disease  a  woman 
should  be  <^iven  every  opportunity.  It  is  a  question 
as  to  whether  all  glands  should  be  removed.  Some 
take  out  healthy  glands  on  suspicion,  but,  as  every 
healthy  gland  has  a  functon  to  perform,  a  great  deal  of 
usefulness  is  lost  by  so  doing. 

Case  H. — Carl  G. — aet.  15.  Eighteen  months  ago 
he  fell  from  a  bicycle  and  injured  his  right  hip.  It  re- 
fused to  get  well,  and  he  was  obHged  to  be  in  bed  for 
eight  weeks.  Since  the  injury  he  has  been  greatly 
troubled  with  his  leg.  At  times  he  could  not  even  sit 
up  and  has  been  confined  to  his  bed  ever  since.  He 
was  sent  to  a  sanitarium  and  treated  for  rheumatism 
for  six  weeks  with  no  result.  On  his  coming  to  me  I 
found  a  distinct  tubercular  history  on  the  maternal 
side.  J  put  him  under  chloroform  and  gave  him  a 
thorough  examination,  and  found  impairment  of  mo- 
tion of  the  right  hip  joint  and  considerable  difference 
in  the  dimensions  of  the  two  legs.  In  length,  from 
ilium  to  malleolus,  the  right  was  one  inch  shorter.  The 
calf  of  the  right  leg  was  one-half  inch  smaller,  and  the 
thigh  less  by  three-fourths  of  an  inch. 

I  painted  the  right  hip  daily  for  a  week  v>rith 
tincture  iodine,  and  gave  him  internally  rhus  toxi- 
codendron. For  six  weeks  I  gave  electricity  daily 
along  the  course  of  the  sciatic  nerves  and  along 
the  hip  and  thigh,  anteriorly  and  posteriorly,  from" 
the  spine  to  the  knee.  He  was  massaged  daily 
by   a   professional   masseur,   and   during   the   entire 

8 


course  oi  treatment  he  wore  a  brace  of  .my  de- 
sign— a  modification  of  Thomas'  extension  brace. 
At  the  end  of  six  weeks  he  went  home  cured ;  the  meas- 
urements of  the  two  legs  are  identical,  and  he  walks, 
runs,  rides  a  bicycle  and  has  full  faculties  of  his  leg  as 
before. 

Case  III. — Mrs.  W ,  aet.  32.     She  came  to  me 

suffering  from  a  growth  of  some  kind  in  the  abdomen. 
The  symptoms  she  presented  were  frontal  and  occipi- 
tal headache,  severe  pain  in  her  back,  prostration, 
urine  frequent  and  scanty,  and  bowels  very  irregular 
and  constipated. 

The  tumor  was  of  such  size  that  it  encroached  upon 
the  free  motion  of  the  lungs,  and  she  had  great  diffi- 
culty in  breathing.  At  times  she  would  become  almost 
asphyxiated.  On  examination  I  found  she  had  a  large 
ovarian  cyst  of  the  left  organ.  She  had  been  to  a  sur- 
geon of  repute  who  had  declined  to  operate,  believing 
that  her  condition  was  so  low  as  to  contra-indicate  it. 
She  was  in  the  hospital  two  days  before  the  operation 
in  order  to  tone  up  the  heart  and  general  condition. 
She  was  given  two-drop  doses  of  digitalis  every  four 
hours,  and  a  whiskey  sling  immediately  before  the 
operation.  She  also  had  hot  water  given  her  three 
times  a  day  in  pint  draughts,  and  a  pint  three  hours 
before  the  operation,  in  order  to  thoroughly  soak  the 
tissues  of  the  body  and  overcome  the  distressing  after- 
thirst. 

Chloroform  was  given  and  the  abdomen  opened. 
The  diagnosis  was  correct.  .  The  cyst  was  found  to 
be  adherent  to  the  peritoneum  and  to  the  tube  and 
broad  ligament  of  the  left  side  as  well  as  to  the  intestines 
and  omentum.  It  was  emptied  of  four  gallons  of  thick, 
heavy,  pea-soup  fluid.    Then,  after  very  careful  dissec- 


lifm*.  flu*  iu\)u'*uiu*  wrrr  \trn\irn  uf»  Jirul  ihr  Mr  |#^ 
rnovcfl,  Thr  |Mr|i(  |c  wftn  «ili(»rt  arirl  ttmuH^  nw\  wan 
(liffirMtl  to  tic,  iMtt  wan  rna'lc  M-citrr  l»y  a  flmiMf  Iran*- 
fixinn  HKatttrr,  All  thr  Hniall  Mrrflin^  |Miint«  wrrc 
rarcfiilly  taken  ii(»  an<l  tied  .iri'l  Itic  alKlotiiinal  ravity 
washed  <Mit  with  ntcrilc  water,  an  dcHpitc  'Mir  mn*t  care- 
ful cfffirts  fluid  leaked  int«»  the  ahdfttnen.  i  )therwi*e 
the  cavity  wonld  have  heen  dressed  perfectly  dry,  nn 
I  !)elicvi'  in  such  cases  that  the  l»acilli.  not  havinff  the 
necessary  moisture  for  their  devchipnicnt,  arc  rctardc<l 
in  j^rowth. 

( )n  account  of  the  extensive  a<lhesions  and  possi- 
ble 9ul)sc(|ucnt  oozing,  I  put  in  a  Mikulicz  tam- 
pon, leaving  two  sutures  loose  for  that  purpose. 
The  remainder  of  the  incision  was  sewed  up  t)y  three 
steps,  i.  c. :  peritoneum,  muscles  and  integument.  The 
wound  was  dressed  antiseptically — the  hcrmetical 
dressing  being  impracticable  with  the  handkercheif  of 
Mikulicz. 

On  the  second  day  the  tampon  was  removed  and 
the  wound  closed,  dressed  hermetically  and  left  till  the 
ninth  day,  when  the  integumental  stitches  of  silk- 
worm gut  were  removed.  The  wound  healed  nicely 
and  kindly  with  minimum  shock  and  no  undue  rise  of 
temperature.  Owing  to  the  water  treatment  there  was 
little  or  no  thirst  after  the  operation.  At  the  end  of 
four  weeks  she  went  home  apparently  well.  She  has 
never  had  any  of  the  former  symptoms  and  feels  like 
a  different  woman.  The  tumor  and  contents  weighed 
forty-five  pounds.  The  operation  was  over  a  year  ago 
and  there  has  been  no  sign  of  weakening  of  the  abdom- 
inal walls. 


